The proposed conservator must complete and sign this form. The person requesting appointment of a conservator must submit the completed and signed form to the court with the conservatorship petition.

This form must remain confidential.
How This Form Will Be Used This form is confidential and will not be a part of the public file in this case. Each proposed conservator must complete and sign a separate copy of this form under rule 7.1050 of the California Rules of Court. The information provided in this form will be used by the court and by the persons and agencies designated by the court to assist the court in determining whether to appoint the proposed conservator as conservator. The proposed conservator must respond to each item. 1. a. Proposed conservator (name): b. Date of birth: c. Social security number: d. Driver's license number: Work: State: Other: e. Telephone numbers: Home: 2. a. b. 3. by 4. a.

I am related to the proposed conservatee as (specify relationship): I have personally known the proposed conservatee for: years,

months.

estate of the proposed conservatee, person I was I was not nominated as conservator of the the proposed conservatee. the spouse or registered domestic partner of the proposed conservatee. a parent of the proposed conservatee. (If you checked "I was," provide documentation in Attachment 3.) I am the spouse of the proposed conservatee. I have I have not filed for legal separation, dissolution of marriage, annulment, or adjudication of nullity of the marriage. (If you checked "I have," explain in Attachment 4.) I am not the spouse of the proposed conservatee. I am the registered domestic partner of the proposed conservatee. I do not I do intend to terminate my domestic partnership with the proposed conservatee. (If you checked "I do," explain in Attachment 5.) I am a former domestic partner of the proposed conservatee. My domestic partnership with the proposed conservatee was terminated on (date): . (Explain circumstances in Attachment 5.) I am neither a current nor former domestic partner of the proposed conservatee. I do I do not owe money or have a financial obligation to the proposed conservatee. (If you checked "I do," explain in Attachment 6.) The proposed conservatee does does not owe money or have a financial obligation to me. (If you checked "does," explain in Attachment 6.) I am I am not an agent for a creditor of the proposed conservatee. If you checked "I am," explain in Attachment 6.) Page 1 of 2

b. 5. a. b. c. 6. a. b. c.

Form Adopted for Mandatory Use Judicial Council of California GC-314 [Rev. July 1, 2009]

I have not I have not I have not I have not I have not I have not I am not I have not I have not

filed for bankruptcy protection within the last 10 years. (If you checked "I have," explain in Attachment 7.) been convicted of a felony or had a felony expunged from my record. (If you checked "I have," explain in Attachment 8.) been charged with, arrested for, or convicted of embezzlement, theft, or any other crime involving the taking of property. (If you checked "I have," explain in Attachment 9.) been charged with, arrested for, or convicted of a crime involving fraud, conspiracy, or misrepresentation of information. (If you checked "I have," explain in Attachment 10.) been charged with, arrested for, or convicted of any form of elder abuse or neglect. (If you checked "I have," explain in Attachment 11.) had a restraining order or protective order filed against me in the last 10 years. (If you checked "I have," explain in Attachment 12.) required to register as a sex offender under California Penal Code section 290. (If you checked "I am," explain in Attachment 13.) previously been appointed conservator, executor, or fiduciary in another proceeding. (If you checked "I have," explain in Attachment 14.) been removed or resigned as a conservator, guardian, executor, or fiduciary in any other case. (If you checked "I have," explain in Attachment 15.) I do not have an adverse interest that the court may consider to be a risk to, or to have an effect on, my ability to faithfully perform the duties of conservator. (If you checked "I have or may have," explain in Attachment 16.) a private professional fiduciary, as defined in Business and Professions Code section 6501(f). (If you checked "I am," respond to item 18. If you checked "I am not," go to item 19.) currently licensed by the Professional Fiduciaries Bureau of the Department of Consumer Affairs. My license status and information is stated in item 1 on page 1 of the Professional . Fiduciary Attachment signed by me and attached to the petition that proposes my appointment as conservator in this matter. (Complete and sign the Professional Fiduciary Attachment and attach it to the petition, or deliver it to the petitioner for attachment, before the petition is filed. See item 3c(7) of the petition. Use form GC-210(A-PF)/GC-310(A-PF) for this attachment.) a responsible corporate officer authorized to act for (name of corporation): a California nonprofit charitable corporation that meets the requirements for appointment as conservator of the proposed conservatee under Probate Code section 2104. I certify that the corporation's articles of incorporation specifically authorize it to accept appointments as conservator. (If you checked "I am," explain the circumstances of the corporation's care of, counseling of, or financial assistance to the proposed conservatee in Attachment 19.)

I have or may have

17. 18.

I am I am

I am not I am not

19.

I am

I am not

20. Do you, or does any other person living in your home, have a social worker or parole or probation officer assigned to him or her? Yes (If you checked "Yes," explain in Attachment 20 and provide the name, address, and telephone No number of each social worker, parole officer, or probation officer.) DECLARATION I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: